Jefferson County Health Assesment 2016 Page1 / 1 100% of survey complete. Question Title 1. In what zip code is your place of residence? 66054 66060 66066 66070 66073 66079 66088 66097 66512 Question Title 2. What is your age? Under 18 18-24 25-34 35-44 45-54 55-64 65+ Question Title 3. What is your identifying gender? Male Female Transgender Other (please specify) Question Title 4. Choose one ethnic identity. Hispanic / Latino Not Hispanic / Latino Question Title 5. Choose one or more racial identities (regardless of ethnicity). White Asian Black or African American Native Hawaiian or other Pacific Islander American Indian or Alaskan Native Prefer not to answer Other (please specify) Question Title 6. Indicate your annual take home pay range. Less than $25,000 $25,000 - $49,999 $50,000 - $74,999 Over $75,000 Question Title 7. How many people live in your household? 1 2 3 4+ Question Title 8. Of those people identified in the above question, how many are dependents? 1 2 3 4+ None Question Title 9. In which county do you work? Atchison Douglas Leavenworth Jefferson Shawnee Other (please specify) Question Title 10. I use these services within Jefferson County more than 50% of the time. (select all that apply) Banking Dining Out Entertainment Medical Care Physical Activity / Recreation Center Purchase Clothing Purchase Gasoline Purchase Vehicle Vehicle Maintenance None Question Title 11. What television station(s) do you get your news from? (select all that apply) WIBW-13 (CBS) KCTV-5 (CBS) KSNT-27 (NBC) KSHB-41 (NBC) KTKA-49 (ABC) KMBC-9 (ABC) WDAF-4 (FOX) I don't watch television. Question Title 12. How do you stay up to date with current events and news? (select all that apply) Newspaper Online Newspaper Television Facebook Twitter YouTube Flyers around town Internet Other (please specify) Question Title 13. What newspaper(s) do you read? (select all that apply) Oskaloosa Independent Valley Falls Vindicator Leavenworth Times Topeka Capital Journal Atchison Globe Lawrence Journal World I don't read the newspaper. Other (please specify) Question Title 14. If jobs were available in Jefferson County, would you work in Jefferson County? Yes No Undecided Question Title 15. What is your career category? Agriculture Banking Construction Education Government Healthcare Sales Technology Other (please specify) Question Title 16. How would you describe your overall health? Excellent Very Good Good Fair Poor Question Title 17. Are you able to visit a doctor when needed in Jefferson County? Yes (proceed to question #19) No Question Title 18. If you answered "NO" to question #17, choose all that apply. No appointment available Can't afford it Can't take time off work No transportation No specialist for my condition I use healthcare outside of Jefferson County Other (please specify) Question Title 19. What type of healthcare coverage do you have? Medicare Medicaid / Kancare ( Amerigroup, United Healthcare, Sunflower) Commercial Health Insurance (Humana, Blue Cross Blue Shield, United Healthcare, Aetna, Signa) No Healthcare Other (please specify) Question Title 20. Select the challenges / concerns that apply to YOU and YOUR HOUSEHOLD. (select all that apply) Alcohol overuse Underage alcohol consumption Illegal drug use Prescription drug overuse Tobacco use Underage tobacco use Suicide Accidental death/injury Traffic injury Transportation Economic growth Unemployment Affordable housing Commute to work Access to healthcare Access to safe, clean drinking water Access to healthy fruits and vegetables Affordable childcare/preschool Domestic / Child abuse Infant mortality Lack of immunization compliance Overweight / Obesity Access to physical activity Stroke Heart problems/concerns High blood pressure Diabetes Cancer Arthritis Lung disease (COPD) None Question Title 21. Which of the following topics do you think are CONCERNS that need to be addressed in Jefferson County? Alcohol overuse Underage alcohol consumption Illegal drug use Prescription drug abuse Tobacco use Underage tobacco use Suicide Accidental death/injury Traffic injury Transportation Economic growth Unemployment Affordable housing Commute to work Access to healthcare Access to safe, clean drinking water Access to healthy fruits and vegetables Affordable childcare / preschool Domestic / Child abuse Infant mortality Lack of immunization compliance Overweight / Obesity Access to physical activity Stroke Heart problems/concerns High blood pressure Diabetes Cancer Arthritis Lung disease (COPD) Question Title 22. What additional health services need to be offered to meet health challenges in you community? Question Title 23. Choose all statements below that apply to you: I exercise at least 3 times per week. I eat at least 5 servings of fruits and vegetables each day. I eat fast food more than once per week. I smoke cigarettes. I chew tobacco. I use illegal drugs. I abuse or overuse prescription drugs. I consume more than 4 alcoholic drinks (if female) or 5 (if male) per day. I use sunscreen or protective clothing for planned time in the sun. I receive a flu shot each year. I have access to a wellness program through my employer. I protect myself from sexually transmitted infections. None of these apply to me. Question Title 24. Which of the preventative procedures have you had in the past 12 months? (select all that apply) Mammogram (if female) Pap Smear (if female) PSA testing (if male) Flu Shot Colonoscopy Rectal Exam Blood Pressure Check Blood Sugar Test Skin Cancer Screening Cholesterol Screening Bone Density Test Dental Cleaning/Dental X-rays Physical Exam Pneumonia Vaccine Tetanus shot every 10 years Sexually Transmitted Infection Testing HIV Testing None of the above Question Title 25. Do you want or need any of the preventative services listed above? Yes No Question Title 26. If "yes", why have you not received those services? Time Access Cost Other (please specify) Question Title 27. The following are concern(s) that I have about Jefferson County: Centralized Hospital Recreation Center Public Transportation Affordable Housing Increase in Employment Opportunity None Question Title 28. Other Comments: Done